What are HIPAA guidelines for employees?

HIPAA guidelines for employees are a set of rules and best practices that help staff at covered entities and business associates handle protected health information (PHI) securely. They include proper training, access controls, administrative safeguards, and procedures to prevent unauthorized use or disclosure of PHI.

Who is considered a covered entity under HIPAA?

Covered entities under HIPAA include health plans, healthcare providers that electronically store, share, or transmit PHI, and healthcare clearinghouses. These entities must follow HIPAA rules to protect patient information.

Do HIPAA rules apply to business associates?

Yes. Since 2009, HIPAA rules apply to business associates—organizations or individuals that handle PHI on behalf of a covered entity. Business associates must implement safeguards, follow HIPAA guidelines, and ensure compliance when managing PHI.

What is considered protected health information (PHI)?

PHI includes any identifiable health information related to an individual's past, present, or future medical conditions, healthcare services, or payment for care. This can include records in electronic, physical, or spoken form, and identifiers such as names, dates, social security numbers, medical record numbers, or biometric data.

What are common employee HIPAA violations?

Common employee HIPAA violations include snooping on patient records, mishandling or leaving medical records exposed, sharing PHI on social media, discussing patient information in public areas, losing or mismanaging devices containing PHI, and sending unsecured messages containing PHI.

How can employers prevent HIPAA violations?

Employers can prevent HIPAA violations by providing regular HIPAA compliance training, implementing administrative safeguards, limiting access to PHI, using secure messaging and devices, monitoring employee actions, and enforcing clear policies and procedures in line with HIPAA guidelines.

What are the consequences of violating HIPAA as an employee?

Violating HIPAA can result in serious consequences, including disciplinary action from the employer, monetary fines, and in severe cases, criminal charges leading to jail time. Both unintentional and intentional violations can carry penalties.

Why is HIPAA training important for employees?

HIPAA training is crucial because it equips employees with the knowledge to handle PHI correctly, recognize potential risks, comply with administrative safeguards, and prevent breaches. Well-trained employees help maintain compliance, protect patient data, and reduce organizational liability.

HIPAA Guidelines For Employees

RSI Security

6 years ago

HIPAA guidelines have been shaping the healthcare industry since the late 1990s, yet many organizations still struggle to comply with their requirements. A common area of concern for covered entities is the protection of patients’ protected health information (PHI). Failing to safeguard this sensitive data can lead to serious consequences, including data breaches, identity theft, fraud, loss of patient trust, fines, and even legal action.

One of the main reasons for HIPAA non-compliance is human error. Employees may unintentionally expose PHI due to a lack of understanding, training, or awareness. While these mistakes are rarely malicious, the U.S. Department of Health and Human Services (HHS) does not accept ignorance as an excuse. That’s why it’s essential to ensure that all team members follow proper HIPAA guidelines for employees and understand their responsibilities in protecting patient information.

Learn more about our HIPAA guidelines for employees to strengthen compliance and protect your organization.

Are Employers Bound by HIPAA?

If your business operates outside the healthcare industry, you might wonder, “Are employers bound by HIPAA?” Even if your organization is not a covered entity, you may still collect employees’ health information for purposes such as Workers’ Compensation or compliance with the Americans with Disabilities Act (ADA).

HIPAA primarily applies to covered entities, which are defined as:

Health plans
Healthcare providers that electronically store, share, or transmit PHI
Healthcare clearinghouses

In short, HIPAA generally does not govern the direct collection of employee health information. However, it does apply to the healthcare entities from whom you gather that information. Ensuring your organization follows proper HIPAA guidelines when interacting with these entities is critical to maintaining compliance.

HIPAA Disclosure Rules

Covered entities may only disclose protected health information (PHI) when allowed by the individual. PHI disclosure is typically limited to purposes such as treatment, payment, or healthcare operations, and is subject to the “minimum necessary” standard.

According to HIPAA Section 164.512:

“A covered entity may use or disclose protected health information without the written authorization of the individual, as described in § 164.508, or the opportunity for the individual to agree or object as described in § 164.510, in the situations covered by this section, subject to the applicable requirements of this section. When the covered entity is required by this section to inform the individual of, or when the individual may agree to, use or disclosure permitted by this section, the covered entity’s information and the individual’s agreement may be given orally.”

Understanding these boundaries is essential for compliance, and your team should be trained to follow proper HIPAA guidelines for employees when handling or requesting PHI.

Business Associates

In 2009, the American Recovery and Reinvestment Act (ARRA) expanded HIPAA’s scope to include business associates. According to the U.S. Department of Health and Human Services (HHS), a business associate is:

“A person or entity that performs certain functions or activities involving the use or disclosure of protected health information (PHI) on behalf of, or provides services to, a covered entity. A member of the covered entity’s workforce is not a business associate. A covered healthcare provider, health plan, or healthcare clearinghouse can be a business associate of another covered entity.”

Business associates perform a wide range of functions that involve PHI, including:

Data analysis, processing, or administration
Claims processing and administration
Utilization review
Quality assurance
Billing and benefit management
Practice management and repricing

These services can be provided by professionals in various fields, such as:

Legal and accounting
Administrative support and consulting
Data aggregation, management, and accreditation
Financial services

Organizations must ensure that their business associates comply with proper HIPAA guidelines for employees, including implementing safeguards to protect PHI. Maintaining oversight of business associates is a key part of a strong HIPAA compliance program.

HIPAA Guidelines for Employees

What is PHI?

If your organization is a covered entity or a business associate, it is critical that you and your employees handle protected health information (PHI) with care. But what exactly counts as PHI? According to the HIPAA Journal:

“Any identifiable health information that is used, maintained, stored, or transmitted by a HIPAA-covered entity or a business associate, in relation to the provision of healthcare or payment for healthcare services. PHI includes not only past and current health information but also future information about medical conditions or physical and mental health related to the provision of care or payment for care. PHI can exist in any form, including physical records, electronic records, or spoken information.”

Understanding PHI is a foundational part of HIPAA guidelines for employees, as mishandling any of this information can lead to serious compliance violations.

The 18 Identifiers That Qualify as PHI

PHI includes any data that can uniquely identify a patient. The 18 HIPAA identifiers are:

Names
All geographic subdivisions smaller than a state (street address, city, county, ZIP code)
Dates (except year) directly related to an individual
Telephone numbers
Fax numbers
Email addresses
Social Security numbers
Medical record numbers
Health plan beneficiary numbers
Account numbers
Certificate/license numbers
Vehicle identifiers and serial numbers (including license plates)
Device identifiers and serial numbers
Web URLs
Internet Protocol (IP) addresses
Biometric identifiers (fingerprints, retinal scans)
Full-face photographs and comparable images
Any other unique identifying number or code

Employees must follow HIPAA guidelines when handling any of these identifiers to protect patient privacy and avoid regulatory penalties

Administrative Safeguards

If your organization is a covered entity or business associate, HIPAA’s Security Rule requires the implementation of specific administrative safeguards to protect electronic protected health information (ePHI). Key safeguards include:

Security Management Process – Identify and analyze potential risks to ePHI. After assessing risks, implement security protocols and procedures to reduce vulnerabilities.
Security Official – Designate a security official responsible for developing, managing, and enforcing security policies and procedures.
Information Access Management – Limit access to PHI according to the “minimum necessary” standard, ensuring that employees only access the information needed to perform their duties.
Workforce Training and Management – Provide ongoing supervision and HIPAA compliance training to all employees handling ePHI. Training should cover security policies, procedures, and the consequences of noncompliance.

By implementing these administrative safeguards and providing proper training, your organization demonstrates a proactive approach to protecting sensitive client information. Following HIPAA guidelines for employees not only reduces the risk of data breaches but also shows regulators and stakeholders that you are committed to compliance and accountability.

Common Employee HIPAA Violations and Mistakes

Employees are often the most common source of HIPAA violations. Most incidents are not malicious but stem from lack of training, awareness, or carelessness. As an employer, it’s your responsibility to educate your team regularly about the risks of noncompliance, for both personal accountability and the protection of your organization.

Effective HIPAA compliance training ensures that employees understand how to handle ePHI properly by:

Ensuring the confidentiality, integrity, and availability of all ePHI they create, receive, maintain, or transmit
Identifying and protecting against reasonably anticipated threats to security or integrity
Preventing impermissible uses or disclosures of PHI
Ensuring compliance across the workforce

Common Employee Violations

To create a robust employer HIPAA compliance checklist, it’s crucial to understand the types of violations employees commonly commit and how to prevent them:

Snooping on Patient Files
- Employees accessing PHI for non-work purposes—such as viewing records of friends, family, or coworkers—is illegal and a serious breach of trust.
- Prevention: Restrict access to PHI strictly to those who need it for their job responsibilities.
Mishandling of Medical Records
- Leaving printed medical records unattended or exposed can lead to unauthorized access.
- Prevention: Store charts, tests, and documents securely immediately after use, and cover any patient identifiers on visible materials.
Social Media Missteps
- Posting patient photos or identifiable information without consent violates HIPAA.
- Prevention: Train employees managing social media to avoid posting any PHI, emphasizing the potential consequences for the patient and organization.
Discussing Patient Information Inappropriately
- Talking about patients outside the scope of their care, at work, home, or public spaces, is a HIPAA breach.
- Prevention: Advise employees to avoid referring to patients by name and to never discuss cases in the presence of unrelated individuals.
Lost or Stolen Devices
- Laptops, tablets, and phones containing PHI are vulnerable to theft or loss.
- Prevention: Require employees to report lost devices immediately and implement security measures such as:
  - Encryption
  - Two-factor authentication
  - Biometric scans
  - VPN access
Messaging Patient Information
- Sharing PHI via unsecured messaging apps can expose sensitive data.
- Prevention: Use encrypted messaging applications for any PHI-related communication.
Exposing PHI on Home Computers
- Reviewing PHI remotely is acceptable, but leaving information visible or unsecured is a violation.
- Prevention: Encourage employees to lock screens when away and ensure all devices are protected with encryption, strong passwords, and dual authentication.

Following these steps and reinforcing proper handling of PHI is a critical part of your HIPAA guidelines for employees, helping prevent breaches and safeguard patient trust.

Alert and Train Your Employees

It is essential that employees understand that their actions, intentional or accidental, can have serious consequences for themselves, your organization, and your patients. Employees found in violation of HIPAA, particularly deliberate breaches, may face significant penalties, including monetary fines and potential jail time.

To protect your business, ensure that all employees receive proper training in accordance with HIPAA guidelines for employees. Effective training should cover:

Correct handling of PHI and ePHI
Security protocols and organizational policies
Potential consequences of noncompliance
Steps for reporting potential breaches

Partnering with experts like RSI Security can help evaluate your organization’s current processes, controls, policies, and training programs. Our comprehensive audits identify gaps between existing practices and HIPAA requirements, providing prescriptive actions and targeted employee training to strengthen compliance.

Take proactive steps today, reach out to RSI Security to ensure that your employees are well-informed and that HIPAA violations do not become a risk to your business